(Philadelphia, PA) - In the July 12 issue of The
American Journal of Managed Care, sociologist Ross
Koppel, PhD, of the Center for Clinical Epidemiology and
Biostatistics at the University of Pennsylvania School of
Medicine, analyzes two well-known medical information technology
systems in light of a study published in the same issue. Researchers
from the Colorado Permanente Medical Group (Palen et al.) found
no positive value to computerized reminders for laboratory tests
needed to accompany 25 major medications. These two systems are
CPOE (computerized physician order entry) and DSS (Decision Support
Systems).

CPOE is regarded as the major technological solution for the problems
of medication ordering error. It eliminates handwriting errors and
instantly sends orders to the pharmacist. Unfortunately, many of
the CPOE software programs are not responsive to the realities of
hospital work; and CPOE systems are often seen by clinicians as
irrational impositions rather than as helpful tools, according to
Koppel.

DSS (Decision Support Systems) is designed to warn physicians about
possible errors and/or provide useful guidelines to prescribing,
including reminders about needed laboratory tests when certain drugs
are prescribed. Often, however, DSS produces obvious and annoying
reminders, false alarms, or useless and constant warnings. Alarm
fatigue is a frequent problem, and many hospitals are forced to
shut off the DSS function within hours of its introduction.

Koppel first points out that DSS is not an integral part of CPOE,
as many who work in health care purport. “Only a very small
proportion of hospitals with CPOE also have DSS; and fewer than
10 percent of hospitals have CPOE,” he notes. Secondly, he
says that by lumping CPOE with the advantages of DSS, CPOE’s
supporters also must take on the problems of DSS: “CPOE is
an imperfect technology that nonetheless has many virtues, which
will increase when it is more fully developed. DSS also has many
virtues, but it has even more problems than CPOE.”

His commentary, entitled, “Defending Computerized Physician
Order Entry From Its Supporters,” addresses the fact that
expansive definitions of CPOE – defining CPOE in ways that
claim the benefits of all sorts of healthcare information technology
– might backfire, resulting in an incorrectly low estimate
of CPOE’s efficacy because overarching definitions of CPOE
will unintentionally pick up the problems with the advantages of
other technologies.

“In the article by Palen and colleagues, the DSS failed drastically,”
explains Koppel. “The reminders had no beneficial impact on
what physicians did. But Palen et al., accepting the overly broad
definition of CPOE, conclude that CPOE was shown to be faulty. I
argue that their findings of DSS’s failure have little to
do with CPOE’s problems. That’s why I’m defending
CPOE from its supporters.”

In general, Koppel states that CPOE is a very promising technology,
but the supporters of CPOE fail to evaluate its strengths and weaknesses.
“They also expansively accept other forms of healthcare information
technology such as electronic health records and electronic medication
administration records under a CPOE portmanteau. By doing that,
they misleadingly claim a wide range of successes. In the Palen
et al study, however, they picked up a rather resounding failure.”

Koppel argues that defining the scope of CPOE is not just an academic
exercise. CPOE has become a major part of federal healthcare policy,
hospital and investor strategies, and hardball market economics.
“In their passion to promote CPOE, its supporters have both
ignored its problems and have embraced an imprecise and ultimately
self-defeating definition,” he says. “We need a clear
definition of the technology and we need independent analyses of
its utility. Currently, we have neither.

“I am a passionate supporter of health information technology
and CPOE,” says Koppel. “I argue, however, that clinicians
and hospitals should seek good healthcare information technology
that helps with patient care and patient safety. Expensive systems
backed by promises and elaborate marketing efforts should not be
the defining characteristics.”

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